UPDATE PATOFISIOLOGI dan MANAJEMEN VERTIGO

ABOE AMAR JOESOEF Departemen/SMF Neurologi FK UNAIR/RSUD dr. Soetomo Surabaya

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Organ of Equilibrium
Evolution from creeping or tetrapedal to erect/ bipedal animals need an excellent equilibrial organ (EO) EO detects, head and body positions & movement. EO is thought the sixth sense organ. But its receptors depend on vestibular, visual and proprioseptic transducers. EO is easy to be adapted.
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Acquired Vestibular Adaptation by Training

Baby: exercise from creeping to erect position. Young: exercise from walking to biking. Professional Maneuvers: acrobatic and cyclic motions. Professional expert: crew of ship, pilot, astronaut.
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Anatomy of Vestibular Organ

Hain, TC, Helminski, JO : Vestibular Reflexs. In Aminoff, MJ, Daroff, RB (eds) : Encyclopedia of the Neurological Sciences. Vol. IV, 2004, p. 657-660.

Hair Cells

Halmagyi, M : Vestibulocochlear nerve (cranial nerve VIII). In Aminoff, MJ, Daroff, RB (eds) : 5 Encyclopedia of the Neurological Sciences. Vol. IV, 2004, p. 671-673.

Neurophysiology of Hair Cells

Baloh, RW : Vestibular System. In Aminoff, MJ, Daroff, RB (eds) : Encyclopedia of the Neurological Sciences. Vol. IV, 2004, p. 661-671.

Mechanism of Transduction

Bear, MF, Connors, BW, Paradiso, MA : Neuroscience Exploring The Brain Williams & Wilkins, Baltimore, 1996, p. 272-288.

Impuls Transmission
Movements S cilia deflect to k cilia Ca influx NT release Afferent Transmission CNS

Perception: vertigo (-) vertigo (+) habituation

Reflex response: normal response abnormal response sensitization

Sign and Symptoms of EO Dysfunction

Guedry, FE : Motion Sickness and its relation to some forms of spatial orientation : Mechanisms and theory. AGARD Lecture series. 175. 1991, p.2.1-2.30.

VERTIGO
Vertigo is a syndrome caused by miscellaneous diseases involving EO dysfunction. Vertigo by definition is :
Truly or illusory movements Can be linear as well as circular. Of the body or surrounding. Followed by vegetative and other signs and symptoms. Caused by equilibrial dysfunction.
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Physiology of EO
Vestibular system Visus Propriocepcis
Sensory information

COORDINATED
CENTRA Oculomotor center Stabilitation of visual field Muscles of the body Static & kinetic equilibrium
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=Known pattern

Pathogenesis of Vertigo
Vestibular system Visus Propriocepsis Sensory information Abnormal stimuli Excessive stimuli Discordant information CENTRA Oculomotor center: nistagmus Muscles: DEVIATION Cortex Become conscious Vertigo Affective component
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= Unknown pattern

Alarm warning

Neuroveg centra

Pathogenesis of Vertigo
Should accommodate the following phenomena :
Variety causes of vertigo. Underlying clinical sequence of syndromes (including psychiatrics). Site and mode of action of drugs. Adaptation/habituation process.

Synaptic theory does accommodate all.

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Sequence of Syndrome ~ MSRS

Motion sickness rating scale from Naval Aerospace Medical Institute, Pensacola, Florida.
1. Dizziness, headache, epigastric awareness, 2. Epigastric discomfort, pallor I, cold sweat I, salivation I. 4. Nausea I, pallor II, cold sweat II, saluvation II. 8. Nausea II, pallor III, cold sweat III, saluvation III. 16. Vomiting or retching.
Graybiel, A, Wood, CD, et al : Diagnostic criteria for grading, the severity of acute motion sickness. Aerospace Med. 1968, 39: 453-455. 14

Two Distinct Syndromes in MSRS

I.
II.

Caused by sympathetic hyperactivity, that is from score 1 to 8 (Nausea). Caused by parasympathetic hyperactivity that is score 16 (vomiting) :
E.G.G exam reveals : Nausea is hypomotility, vomiting is hypermotility.

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In Animal model of MS showed: release CRF ~ speed & duration of rotation or intensity of stress. In aplysia model of synaptic plasticity revealed :
Sensitization ~ synaptic R (up-regulation). Habituation ~ synaptic R ( down-reg. ).

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ETIO VERTIGO
Organic diseases Psychiatric disturbences Physiologic dysfunction Prof. Oosterveld : 100 diseses. Physiologic : Barany chair rotation, Caloric test, motion sickness (Ms).
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Pemeriksaan
1. 2. 3. 4. 5. 6. 7. Anamnesa cermat Pemeriksaan nistagmus Pemeriksaan neurologi Pemeriksaan THT Pemeriksaan keseimbangan. Pemeriksaan lab & radiologik Pemeriksaan ENG
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Anamnesa
KU spesifitas vertigonya Sindroma atau mandiri Pola serangan Pengaruh posisi Obat/ minuman Interne (DM, lambung) Kardiovaskuler THT Neuropsikiatri Trauma
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Duration of vertigo episode can provide an indication of underlying cause

Duration of vertigo episodes Seconds Minutes or hours A day or more
BPPV Menieres disease Perilymph fistula Migraine Transient ischemic attack Vestibular neuritis Multiple sclerosis Brainstem stroke

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Vertigo of Central origin: causes

Condition Migraine Details Vertigo may precede migraines or occur concurrently Ischaemia or haemorrhage in Vascular disease vertebrobasilar system can affect brainstem or cerebellum function Demylination disrupts nerve impulses Multiple sclerosis which can result in vertigo Vertigo resulting from focal epileptic Vestibular epilepsy discharges in the temporal or parietal association cortex Cerebellopontine tumours Benign tumours in the internal auditory meatus
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Vertigo of Peripheral origin: causes

Condition
Benign paroxysmal positional vertigo (BPPV) Menieres disease

Details
Brief, position-provoked vertigo episodes caused by abnormal presence of particles in semicircular canal. An excess of endolymph, causing distension of endolymphatic system. Vestibular nerve inflammation, most likely due to virus. Labyrinth inflammation due to viral or bacterial infection. Compromises blood flow to the labyrinthine. Damage to the labyrinthine after head trauma. Typically caused by labyrinth membrane damage resulting in perilymph leakage into the middle ear. Inappropriate immunological response that attacks inner ear cells.

Vestibular neuronitis Acute labyrinthitis Labyrinthine infarct Labyrinthine concussion Perilymph fistula
Autoimmune inner ear disease

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VERTIGO PERIPHERAL vs CENTRAL

Symptom Likely aetiology Peripheral Central

Vertigo episodes Symptom onset Imbalance Nausea, vomiting Auditory symptoms Neurological symptoms Changes in mental status/ consciousness Compensation/resolution

Mild/moder ate Sudden Mild/mod. Severe Common Rare Infrequent Rapid

Chronic and unremitting Gradual Severe Varying Rare Common Sometimes Slow
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VERTIGO
With ENT

PAROXYSMAL
Morbus Meniere Arachnoiditis TIA a. Vertebralis Posterior tumor Odontogenic

CHRONIC
OMC Meningitis TB Labirintitis C Ototoksik

ACUTE
Trauma labirint Zoster otikus Neuritis vestibularis Labirintitis akuta

Without ENT

TIA a. Vertebrobasiler Epilepsy Migren Stomachclaesa

Contusio/ Comosio Ensefalitis Hypoglycaemia Eyes disorders Psychogenic Cardiovasculer disease

Neuronitis Vesti. Neuritis Vesti. Epidemi Vertigo. MS Hematobulbi

Posisi

Laten PPV
Benign PPV

Hypotentionorthostatik Vertigo Cervicalis

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Obat-obat penyebab vertigo

Streptomisin Anti konvulsi Fenilbutason Kinin Penenang Neomisin Gentamisin Anti hipertensi Kanamisin

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Gaze nistagmus sentral

Penduler. Arah vertikal murni. Rotator murni. Gaze nistagmus murni. Nistagmoid.

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Ciri nistagmus perifer

Latensi 2-20 detik. Nistagmus < 2 menit. Vertigo . Pada ulangan nistagmus (-)

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CURRENT TREATMENT OPTIONS

1.Treat the underlying cause

Pharmacotherapy Particle repositioning procedure (in BPPV) Surgery

2.Symptomatic
Pharmacotherapy

3.Rehabilitative
To promote long-lasting neural reorganisation
Vestibular rehabilitation exercises

Therapeutic option Depends on the type and cause of vertigo

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SYMPTOMATIC TREATMENT
ANTIVERTIGO

I. Vestibular Suppressant
1. Ca antagonist : Flunarizin 2. Vasodilator : Betahistine 3. Tranquilizer : diazepam, haloperidol, sulpiride 4. Antihistamin : Difenhidramine, meclizine. 5. CNS stimulant: ephedrin, amphetamin

II. Antiemetic 1. Anticholinergic : atropine, scopolamine

2. Phenotiazine : Prochlorperazine, metoclopramide. Side effects: sedation, extrapyramidal.
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BETASERC Significantly more Effective vs Flunarizine on

Improving DHI
70 60
Total DHI Score
54.4

*: p<0.05 vs flunarizine
51.6

50 40 30 20 10 0 Betaserc 36mg/day Baseline Flunarizine 10 mg/ day 4 weeks 8 weeks

24.3 17.8 25.9 22.5

DHI: Dizziness Handicap Inventory

Author A, Author B et al. Title of Article. Journal 2002; Vol: page. Author A, Author B et al. Title of Article. Journal 2002; Vol: page. Author A, Author B et al. Title of Article. Journal 2002; Vol: page.

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Improvement in Patients with Menieres Disease

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number of patients

Total 28 Patients

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12 10 8 6 4 2 0 complete relief partial relief No response

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VESTIBULAR REHABILITATION EXERCISE

Mechanism: neural learning and neural reorganization. Aim: to promote adaptation and compensation of the nervous system Particularly useful when:
Medical therapy is ineffective Patients have poor central integration or motor function

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TERIMA KASIH
SEMOGA BERMANFAAT

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